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All-or-None Measurement of Health Care Quality—Reply

All-or-None Measurement of Health Care Quality—Reply In Reply: Dr Van Matre offers an example of measuring diabetes care using 5 elements for patients A, B, and C. Patient A receives all needed care; patient B receives almost all needed care; and patient C receives none of the 5 elements. If we wish to focus on comparing patient B with patient C, then as Van Matre correctly states the particular all-or-none measure we used as an illustration in our article would not be helpful. An all-or-none measure with different elements (including, for example, the availability of access to affordable care) would be more suitable. The focus in our illustrative example of the all-or-none approach was to highlight the differences in care between patients A and B. More generally, as is true of all metrics, any specific all-or-none measure will be useful for some purposes and not for others. Van Matre also cites as a problem the possibility that the all-or-none measure would improve over time and approach the upper end of the scale. That of course would be a good thing, and under that circumstance new priorities or new patient-centered measures will be needed. His suggestion of using parts per million as a unit could be useful if the “million” refers to a real item or interaction, as it does in the high-volume parts industries where it originated. Using defects per million patients in a hospital with 10 000 admissions per year seems contrived. Dr Chelmowski expresses concern about how timed elements might be used. As an example, he notes that all-or-none measures treat missing a timed element (such as having had a foot examination within 12 months) by 1 week with the same penalty as missing it by several years. This measurement challenge is not unique to the all-or-none approach. The problem arises from the loss of information from collecting a continuous measure (such as time since last foot examination) and converting it to a discrete variable, requiring only a “yes” or “no” answer. We believe the best candidates for an all-or-none set are process measures that are inherently discrete, such as whether or not a needed drug is prescribed. In response to our Commentary, we have also received poignant comments from frontline clinicians lamenting that by raising the bar we were making their lives more difficult because they were already trying as hard as they could. Trying harder is not the answer. Our major objective was to emphasize the crucial value of “system” reliability—the sorts of supports to clinical practice that make it far easier for physicians and other clinicians to deliver what science says should be done, as reliably as possible. Bundling good measures together makes system flaws far easier to see and in our opinion places responsibility more firmly on the shoulders of the organizations and groups that ought to be supporting the work of physicians and nurses more adequately. Back to top Article Information Financial Disclosures: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

All-or-None Measurement of Health Care Quality—Reply

Nolan, Thomas W.; Berwick, Donald M.
JAMA , Volume 296 (4) – Jul 26, 2006
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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.296.4.393-a
Publisher site
See Article on Publisher Site

Abstract

In Reply: Dr Van Matre offers an example of measuring diabetes care using 5 elements for patients A, B, and C. Patient A receives all needed care; patient B receives almost all needed care; and patient C receives none of the 5 elements. If we wish to focus on comparing patient B with patient C, then as Van Matre correctly states the particular all-or-none measure we used as an illustration in our article would not be helpful. An all-or-none measure with different elements (including, for example, the availability of access to affordable care) would be more suitable. The focus in our illustrative example of the all-or-none approach was to highlight the differences in care between patients A and B. More generally, as is true of all metrics, any specific all-or-none measure will be useful for some purposes and not for others. Van Matre also cites as a problem the possibility that the all-or-none measure would improve over time and approach the upper end of the scale. That of course would be a good thing, and under that circumstance new priorities or new patient-centered measures will be needed. His suggestion of using parts per million as a unit could be useful if the “million” refers to a real item or interaction, as it does in the high-volume parts industries where it originated. Using defects per million patients in a hospital with 10 000 admissions per year seems contrived. Dr Chelmowski expresses concern about how timed elements might be used. As an example, he notes that all-or-none measures treat missing a timed element (such as having had a foot examination within 12 months) by 1 week with the same penalty as missing it by several years. This measurement challenge is not unique to the all-or-none approach. The problem arises from the loss of information from collecting a continuous measure (such as time since last foot examination) and converting it to a discrete variable, requiring only a “yes” or “no” answer. We believe the best candidates for an all-or-none set are process measures that are inherently discrete, such as whether or not a needed drug is prescribed. In response to our Commentary, we have also received poignant comments from frontline clinicians lamenting that by raising the bar we were making their lives more difficult because they were already trying as hard as they could. Trying harder is not the answer. Our major objective was to emphasize the crucial value of “system” reliability—the sorts of supports to clinical practice that make it far easier for physicians and other clinicians to deliver what science says should be done, as reliably as possible. Bundling good measures together makes system flaws far easier to see and in our opinion places responsibility more firmly on the shoulders of the organizations and groups that ought to be supporting the work of physicians and nurses more adequately. Back to top Article Information Financial Disclosures: None reported.

Journal

JAMA – American Medical Association

Published: Jul 26, 2006

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